Transcatheter mitral valve repair confers poor outcomes in chronic kidney disease
ORLANDO, Fla. — Patients with chronic kidney disease had worse outcomes than patients with normal renal function after transcatheter mitral valve, especially in women, researchers reported at the American College of Cardiology Scientific Session.
Poor outcomes were more pronounced the worse the creatinine clearance rate.
“Patients with renal disease are also very often excluded from large trials because they are considered high risk, and so they remain an understudied population. Mitral regurgitation is not uncommon in these patients, but more often than not, they were considered too high risk for mitral valve surgery. With the availability of transcatheter mitral valve repair, the playing field changed, such that we can now offer these high-risk patients a therapeutic strategy that may help them with quality of life and potentially decrease adverse cardiovascular events,” Binita Shah, MD, interventional cardiologist and assistant professor of medicine at NYU Langone Health, and a Cardiology Today Next Gen Innovator, said in an interview.
Shah and colleagues analyzed 5,241 patients from the Society of Thoracic Surgeons (STS)/ACC Transcatheter Valve Therapy (TVT) registry who had a procedure with a transcatheter mitral valve repair system (MitraClip, Abbott Vascular) between November 2013 and June 2016. Patients were stratified by creatinine clearance rate.
“The STS/ACC TVT registry offered a unique opportunity with access to a large number of patients with renal disease and valve disease,” Shah told Cardiology Today’s Intervention. “Anything that we can do to better understand how to best manage patients with renal disease is important because they are a different population that deserves a separate look into what would help them the most.”
The primary outcome was a composite of all-cause mortality, stroke and new requirement for dialysis. Secondary outcomes included 30-day and 1-year mortality.
The primary outcome occurred in 1.5% of those with creatinine clearance greater than 60 mL/min, 2.7% of those with creatinine clearance 30 mL/min to 60 mL/min or less, 5.3% of those with creatinine clearance of at least 30 mL/min and 7.1% of those on dialysis (P < .001).
Shah and colleagues also found that worse creatinine clearance was associated with overall all-cause mortality (P < .001), new requirement for dialysis (P = .02), 30-day all-cause mortality (P < .001) and 1-year all-cause mortality (P < .001), but not stroke (P = .14).
After adjustment for demographic, clinical and procedural factors, the association between the primary outcome and creatinine clearance rate was stronger in women than men, according to the researchers.
For men, compared with those with creatinine clearance greater than 60 mL/min, those with creatinine clearance of 30 mL/min or less had elevated risk for the primary outcome (adjusted OR = 2.72; 95% CI, 1.26-5.87), but that was not true for those with creatinine clearance of 30 mL/min to 60 mL/min or less, or those on dialysis.
However, for women, compared with those with normal creatinine clearance, risk for the primary outcome was greatly elevated in the other creatinine clearance groups (aOR for 30 to 60 mL/min = 6.11; 95% CI, 2.13-17.6; aOR for 30 mL/min = 13; 95% CI, 4.43-38.4; aOR for dialysis = 16.8; 95% CI, 4.05-69.6).
“There are two take-home points here,” Shah said in an interview. “No. 1, patients with renal disease continue to have a poor survival despite transcatheter mitral valve repair — 1 in 5 patients with stage 3 renal disease and almost 1 in 3 patients with stage 4 or 5 renal disease are dead at 1-year follow-up — and this needs to be included in the shared decision-making process. No. 2, women with renal disease do worse than men with renal disease who undergo transcatheter mitral valve repair. The finding of women doing worse than men with renal disease after transcatheter mitral valve repair has not been observed before, and these sex disparities in outcomes warrant further investigation.”
However, she said, there is still a role for transcatheter mitral valve repair in chronic kidney disease “in potentially improving quality of life and reducing admissions due to heart failure.” – by Erik Swain
Shah B, et al. Abstract 1127-394. Presented at: American College of Cardiology Scientific Session; March 10-12, 2018; Orlando, Fla.
Disclosure: Shah reports no relevant financial disclosures.